Authors: Umaru Kabuye, John Damulira, Maxwel Dancan Okuku
Categories: Case Report, Appendico-ileal knotting, Case report, Emergent laparotomy, Small bowel obstruction
Source: International Journal of Surgery Case Reports
Authors: Umaru Kabuye, John Damulira, Maxwel Dancan Okuku
Small bowel obstruction (SBO) is a common surgical emergency with various causes. However, SBO resulting from appendicitis is uncommon and often overlooked. Appendico-ileal knotting, a rare and dangerous form of SBO, occurs when the appendix becomes twisted around the small intestine, leading to strangulation. Despite being reported since 1901, there have been very few documented cases of this condition. Diagnosing appendico-ileal knotting preoperatively is challenging, and even imaging techniques like computed tomography scans may not provide definitive diagnostic findings.
Our current case report is a valuable addition to the limited literature and enhances understanding of this infrequent cause of SBO from a resource limited setting.
We present the case of a 28-year-old female who presented with symptoms of dynamic SBO, including abdominal pain, vomiting, and constipation. Preoperative evaluation couldn't determine the exact cause.
Diagnosis of a strangulated ileum was discovered, with the appendix identified as the source intraoperatively, leading to an open retrograde appendectomy. Postoperatively, the patient received IV ceftriaxone (1 g daily), metronidazole (500 mg tds), paracetamol (1 g tds), and IV crystalloids. Oral intake resumed gradually, and discharge occurred on day 4. Follow-up on 10th day was uneventful.
Appendico ileal knotting is a rare cause of mechanical SBO. Knowledge of its pathophysiology, diagnosis, and management is very crucial to reduce its associated morbidity and mortality.
SBO is one of the commonest causes of acute surgical abdomen with varying causes. An adequate understanding of physiopathology and etiology of SBO is critical to ease its treatment [1].
The commonest cause of SBO in Uganda is hernias, followed by bands, gut twisting, and malignancies [2]. Appendico-ileal knotting is an uncommon cause of SBO documented since 1901 [3]. Preoperative diagnosis is not as obvious making its management dependent on operation findings [1].
Our current case report is a valuable addition to the limited literature and enhances understanding of this infrequent cause of SBO from a resource limited setting.
This work was reported in line with the SCARE criteria [4].
A 28-year-old female, referred from a peripheral clinic, presented to the Accident and Emergency Department of our community Hospital with a five-day history of crampy moderate generalized abdominal pain. She also experienced five episodes of bilious non-blood-stained vomiting, mild abdominal distension, and had not been able to pass stool or flatus.
The patient reported no history of dysuria, or abnormal vaginal discharge but was in her menstrual period and was receiving management for premenstrual syndrome at the referring facility. No prior report of any history of groin or any other abdominal masses. She denied any other known medical, family, or genetic illnesses. The patient was a mother of two, with two previous successful vaginal deliveries and no history of miscarriage. She had no significant medical or surgical history, and had never undergone any gynecological procedures. She lived with her husband, did not smoke, and abstained from alcohol. She feeds on a mixed diet.
On physical examination, she was tachycardic and tachypneic to the level of 115beats per minute and 23breaths per minute respectively. Blood pressure (BP) 120/70 mmHg, atmospheric oxygen saturation of 95 % and her temperature was 37.5 °C.
Her abdomen was mildly distended with visible bowel peristaltic waves with no therapeutic or surgical scars, intact hernia orifices, hyperactive bowel sounds, and tympanic percussion note with generalized mild tenderness that was more marked in the right lower iliac region. On digital rectal examination (DRE), she had a normal anal sphincter tone, an empty rectum with no masses felt or blood stains on examining finger.
On investigation, the patient's white blood cell (WBC) count was 9.73 × 10^9/L with a neutrophilia of 64.9 %. The urine beta-HCG test was negative. Due to the inability to access a CT scan, abdominal ultrasonography was performed, revealing dilated bowel loops measuring 4.3 cm in width with intraluminal fluid content. Increased peristaltic activity was observed around the umbilicus. Additionally, a plain erect abdominal X-ray demonstrated dilated central bowel loops and the presence of multiple air-fluid levels (Fig. 1).Fig. 1Plain erect abdominal radiograph OF 28-year female. Note the dilated bowel loop (DL) and multiple air-fluid levels (A1, A2, A3).Fig. 1
A diagnosis of SBO was made, and the patient, with an ASA score of III, was taken to the operating room after undergoing appropriate preoperative optimization.
During surgery, findings included dilated small bowel loops and a closed-loop obstruction 10 cm distal to the ileum due to an appendicular knot. The appendix tip was infected with mild pus, but no masses were observed. Pressure marks were present 5 cm and 10 cm from the ileocecal junction (Fig. 2). A retrograde appendectomy was performed with a 2/0 Vicryl purse-string suture after releasing the knot. The abdomen was lavaged with warm saline before closure using 2/0 nylon sutures, and no drain was left.Fig. 2Intra-operative findings of 28-year Note the dilated small bowel loop (DL), closed obstruction loop (CL), appendicular knot (AK), and pressure marks (PM).Fig. 2
Postoperatively, the patient received IV ceftriaxone (1 g daily), metronidazole (500 mg tds), paracetamol (1 g tds), and IV crystalloids. On the second day, oral sips were initiated. The patient was discharged home on the fourth day and was reviewed on the 10th postoperative day in the outpatient clinic; with no reported complications. The detailed management schedule over 10 days is displayed in (Fig. 3).Fig. 3Management schedule of a 28-year-old female over a period of 10 days.Fig. 3
Acute SBO is a frequent surgical emergency [1]. It can be classified as either dynamic or adynamic. The dynamic form of SBO has varying causes with post-operative adhesions topping the list in the developed countries whereas hernias are the most implicated in Uganda followed by gut twisting and malignancies [2].
However SBO sequalae to appendicitis is very uncommon with the initial cases reported by Hotchkiss et al., in 1901 and Hawkes in 1909 [3]. Bhandari in 2009 described four ways by which appendicitis induces SBO. These paralytic ileus, mechanical (without strangulation), strangulation (of the intestine), and intestinal obstruction due to mesenteric ischemia [1,3].
An appendicular tourniquet causes mechanical obstruction of the bowel in contrast to other appendicular pathologies, which are seen as small bowel obstruction secondary to ileus [5]. Strangulation occurs when the appendix twins around a bowel loop, or when inflamed appendix sticks to caecum, small intestine or posterior peritoneum followed by entrapment of a bowel in the gap created [1].
The knots rapidly induce bowel obstruction, strangulation, and ischemia in the affected segment, leading to gangrene and perforation. These complications trigger a severe inflammatory response, metabolic acidemia, and electrolyte imbalances, including hypochloremia and hypokalemia, often exacerbated by prolonged vomiting. Swift diagnosis and surgical intervention are critical to preventing rapid deterioration and death [6].
Diagnosis of SBO is based on clinical presentation and radiographic findings. The main features are colicky abdominal pain, vomiting, obstipation, and abdominal distension [7]. Most patients with appendico-ileal knotting present with abdominal pain, vomiting and constipation and fever evidenced by the past cases that have been documented [1,5,8,9].
Preoperative diagnosis of small bowel obstruction caused by an appendicular tourniquet is challenging due to its rarity and is not reliably detected using abdominal X-rays or ultrasound [5]. CT scans, with sensitivity, specificity, and accuracy of 83 %, 93 %, and 91 % respectively, are critical when clinical, biochemical, and X-ray findings are inconclusive [1]. A contrast-enhanced CT of the abdomen and pelvis may offer valuable insights, with an experienced radiologist potentially identifying the appendicular tourniquet at the transition point [5]. However, limited access to biochemical tests and CT imaging in low-income regions, such as rural Uganda, increases the risk of delayed intervention and adverse patient outcomes. Thus, heightened awareness and a strong index of suspicion among healthcare providers are crucial.
In our patient, a preoperative diagnosis of small bowel obstruction due to an intestinal band was made using a plain erect abdominal X-ray. The definitive diagnosis of appendico-ileal knotting was established intraoperatively.
Recent studies propose nonoperative management for non-ruptured acute appendicitis with specific criteria, aiming to prevent appendix perforation and intra-abdominal abscess formation. This approach is recommended for cases with an appendiceal diameter of 1.1 cm or less, without complicating factors such as fecalith, abscess, or phlegmon [6].
The surgical management of appendico-ileal knots is tailored to the extent of strangulation and bowel involvement. It encompasses a range of procedures, from open or laparoscopic appendectomy to right hemicolectomy, depending on the specific requirements of each case [1].
In this case, intraoperative findings revealed that the appendix was entangled with a segment of the terminal ileum, resulting in a closed-loop obstruction. No fibrous band was detected. The terminal ileum was released and was viable, while the distal appendix was gangrenous. A retrograde appendectomy was performed.
Appendico-ileal knotting is a rare cause of SBO that requires prompt recognition, appropriate imaging, and emergent exploratory laparotomy for diagnosis and management.
Surgeons should be aware of this possibility to ensure timely intervention and reduce associated morbidity and mortality. Early identification and intervention are crucial in preventing complications and improving patient outcomes.
Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
This case report received an exemption from ethics approval by the Kampala International University Research and Ethics Committee (KIU-REC), as case reports are deemed not to constitute research at the institution.
No financial support was received by the author(s) for the report, authorship, and publication of this article.
UK wrote the manuscript, JD and MDO reviewed it, and all authors approved the final version for publication.
Umaru Kabuye.
N/A.
All authors declare no conflict of interest.